1093980005 NPI number — SUREKHA PENDYAL RD

Table of content: SUREKHA PENDYAL RD (NPI 1093980005)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093980005 NPI number — SUREKHA PENDYAL RD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PENDYAL
Provider First Name:
SUREKHA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093980005
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/14/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
06/13/2020
NPI Reactivation Date:
07/10/2020

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
BOX 103857, GSRB1, 905 S LASALLE ST ROOM # 2060
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DURHAM
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27710-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-681-1932
Provider Business Mailing Address Fax Number:
919-684-0927

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3000 ERWIN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DURHAM
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27705-4504
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-961-1932
Provider Business Practice Location Address Fax Number:
919-684-0927
Provider Enumeration Date:
04/30/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X , with the licence number:  L001293 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)